Clinical evaluation of patients with moderate to severe Alzheimer disease

Varandas, Paulo Rogério Borges Rosmaninho; Funari, Rossana Russo

doi:10.1590/S1980-57642008DN10300012

Abstract

Today, Alzheimer disease has become a serious risk to individual and public health, due to the significant incapacity it causes patients, its influence on family members and caregivers, along with the ensuing direct and indirect costs. Objectives: To build the profile of patients with moderate/severe AD, in the Geriatric Clinic Service of Cognitive Alterations of the Medical School at Universidade de São Paulo, by studying demential and comorbidity conditions and the degree of effectiveness of the therapies applied. Methods: 30 patients with moderate or severe AD were selected, (77.8±7.29 years). Age, sex, schooling, prevalent comorbidities/treatments and respective clinical-laboratorial effectiveness were analyzed. Instruments were applied to evaluate the cognitive and behavioral condition and dementia control therapies. Results: Most frequent comorbidities were arterial hypertension (80%) and diabetes (43.3%). A maximum dose of rivastigmine was observed in 43% of the patients, where 76% experienced adverse effects. Severe patients presented more cases of uncontrolled comorbidities, such as hypertension (P<0.001), as well as more behavioral alterations (P<0.001) and functional loss (P=0.004). Patients with greater behavioral alterations proved to be more functionally dependent (P=0.002), having less comorbidity control (P=0.004). Conclusions: In this population, a high incidence of comorbidities, frequent behavioral alterations and difficulties in therapy management were noted due to the severity of the dementia condition. New therapies for more adequate control of severe dementia should be studied.

Key words:
Alzheimer disease; therapy; comorbidities; aged.

Resumo

Hoje em dia, a doença de Alzheimer (DA) tornou-se um sério risco de saúde individual e coletivo, em decorrência da significativa incapacidade que acarreta aos pacientes, das influências sobre os familiares e cuidadores, além dos custos diretos e indiretos que ocasiona. Objetivos: Traçar perfil dos pacientes portadores de DA moderada/grave, do Ambulatório de Alterações Cognitivas - Serviço de Geriatria da Faculdade de Medicina da Universidade de São Paulo, estudando-se quadro demencial, comorbidades e grau de eficácia das terapêuticas aplicadas. Métodos: Selecionados 30 pacientes com DA moderada e grave, (77,8±7,29 anos). Analisou-se idade, sexo, escolaridade, comorbidades prevalentes/tratamentos e respectiva eficácia clínico-laboratorial. Aplicaram-se instrumentos específicos para avaliação do quadro cognitivo,comportamental e avaliação da terapêutica para controle demencial. Resultados: Comorbidades mais freqüentes: hipertensão arterial 80% e diabetes 43,3%. Uso de rivastigmina em dose máxima ocorreu em 43% pacientes, 76% efeitos colaterais. Pacientes graves apresentaram mais casos de comorbidades descompensadas, como hipertensão (P<0,001), mais alterações de comportamento (P<0,001) e perdas funcionais (P=0,004). Pacientes com maiores alterações comportamentais apresentaram-se mais dependentes funcionalmente (P=0,002) e com pior controle de comorbidades (P=0,004). Conclusões: Nessa população estudada observou-se alta incidência de comorbidades, alterações comportamentais freqüentes, dificuldades no manejo terapêutico, decorrentes da gravidade do quadro demencial. Novas terapêuticas devem ser pesquisadas para controle mais adequado de demenciados graves.

Palavras-chave:
doença de Alzheimer; terapêutica; comorbidades; idosos.

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References

¹
Corey-Bloom J, Alzheimer's disease. In: Miller AE, editor. Dementia. Continuum from the American Academy of Neurology. New York: Lippincott Williams & Wilkins; 2004;21:23-57.
²
Herrera Jr E, Caramelli P, Silveira AS, Nitrini R. Epidemiologic survey of dementia in a community-dwelling Brazilian population. Alzheimer Dis Assoc Disord 2002;16:103-108.
³
Doody RS, Stevens JC, Beck C. et al. Practice parameter: management of dementia (an evidence-based review). Report of the Quality standards Subcommittee of the American academy of neurology. Neurology 2001;56:1154-1166.
⁴
Rapport BJM. Does this patient have Alzheimer disease? Diagnosing and treating dementia. Cleve Clin J Med 2003;2:630-633.
⁵
Nitrini R, Caramelli P, Herrera E Jr, et al. Mortality from dementia in a community-dwelling Brazilian population. Int J Geriatr Psychiatry 2005;20:247-253.
⁶
Bynum JPW, Rabins PV, Weller W, et al. The relationship between a dementia diagnosis, chronic illness, medicare expenditures, and hospital use. J Am Geriatr Soc 2004;52:187-194.
⁷
Hill J W, Futterman R, Mastey V, et al. Alzheimer's disease and related dementias increase costs of comorbidies in managed medicare. Neurology 2002;58:62-70.
⁸
Consensus Recommendations for the Post-Mortem Diagnosis of Alzheimer's Disease. The National Institute on Aging and Reagan Institute Working Group on Diagnostic Criteria for Neuropathological Assessment for Alzheimer's Disease. Neurobiol Aging 1997;18:S1-S2.
⁹
Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A pratical method for grading the cognitive state of patients for the clinical. J Psychiat Res 1975;12:189-198.
¹⁰
Scarpini E, Scheltens P, Feldman H. Treatment of Alzheimer's disease: current status and new perspectives. Lancet Neurol 2003;2:539-547.
¹¹
Galasko D, Bennett D, et al. An inventory to access activities of daily living for clinical trials in Alzheimer's disease. Alzheimer Dis Assoc Disord 1997;11(Suppl 2):S33-S39.
¹²
Galasko D, Jin S, et al. Detailed assessment of cognition and activities of daily living in moderate to severe Alzheimer's disease. Neurobiol Aging 2000;21(Suppl 1):S168.
¹³
Cummings JL, Gray K, et al. The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308-2314.
¹⁴
Reisberg B, Burns A, et al. Diagnosis of Alzheimer's disease: report of an Internacional Psychogeriatric Association special Meeting Work group under the co-sponsorship of Alzheimer's Disease International, the European Federation of Neurological societies and the World Psychiatric association. Int Psychogeriatr 1997;9(Suppl 1):11-38.
¹⁵
Fu C, Chutt DJ, et al. Comorbidity in dementia. Arch Pathol Lab Med 2004;128:32-38.
¹⁶
Brauner DJ, Muir JC, Sachs GA. Treating non-dementia illness in patients with dementia. JAMA 2000;283:3230-3235.
¹⁷
Tariot P. Medical management of advanced dementia. J Am Geriatr Soc 2003;51(5 Suppl Dementia): S305-313.
¹⁸
Bertolucci PHF. Doença de Alzheimer: o que esperar do tratamento e como identificar a resposta terapêutica? Alzheimer 2005;1:1-8.

Publication Dates

Publication in this collection
Jul-Sep 2007

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹
Corey-Bloom J, Alzheimer's disease. In: Miller AE, editor. Dementia. Continuum from the American Academy of Neurology. New York: Lippincott Williams & Wilkins; 2004;21:23-57.

[2] ²
Herrera Jr E, Caramelli P, Silveira AS, Nitrini R. Epidemiologic survey of dementia in a community-dwelling Brazilian population. Alzheimer Dis Assoc Disord 2002;16:103-108.

[3] ³
Doody RS, Stevens JC, Beck C. et al. Practice parameter: management of dementia (an evidence-based review). Report of the Quality standards Subcommittee of the American academy of neurology. Neurology 2001;56:1154-1166.

[4] ⁴
Rapport BJM. Does this patient have Alzheimer disease? Diagnosing and treating dementia. Cleve Clin J Med 2003;2:630-633.

[5] ⁵
Nitrini R, Caramelli P, Herrera E Jr, et al. Mortality from dementia in a community-dwelling Brazilian population. Int J Geriatr Psychiatry 2005;20:247-253.

[6] ⁶
Bynum JPW, Rabins PV, Weller W, et al. The relationship between a dementia diagnosis, chronic illness, medicare expenditures, and hospital use. J Am Geriatr Soc 2004;52:187-194.

[7] ⁷
Hill J W, Futterman R, Mastey V, et al. Alzheimer's disease and related dementias increase costs of comorbidies in managed medicare. Neurology 2002;58:62-70.

[8] ⁸
Consensus Recommendations for the Post-Mortem Diagnosis of Alzheimer's Disease. The National Institute on Aging and Reagan Institute Working Group on Diagnostic Criteria for Neuropathological Assessment for Alzheimer's Disease. Neurobiol Aging 1997;18:S1-S2.

[9] ⁹
Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A pratical method for grading the cognitive state of patients for the clinical. J Psychiat Res 1975;12:189-198.

[10] ¹⁰
Scarpini E, Scheltens P, Feldman H. Treatment of Alzheimer's disease: current status and new perspectives. Lancet Neurol 2003;2:539-547.

[11] ¹¹
Galasko D, Bennett D, et al. An inventory to access activities of daily living for clinical trials in Alzheimer's disease. Alzheimer Dis Assoc Disord 1997;11(Suppl 2):S33-S39.

[12] ¹²
Galasko D, Jin S, et al. Detailed assessment of cognition and activities of daily living in moderate to severe Alzheimer's disease. Neurobiol Aging 2000;21(Suppl 1):S168.

[13] ¹³
Cummings JL, Gray K, et al. The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308-2314.

[14] ¹⁴
Reisberg B, Burns A, et al. Diagnosis of Alzheimer's disease: report of an Internacional Psychogeriatric Association special Meeting Work group under the co-sponsorship of Alzheimer's Disease International, the European Federation of Neurological societies and the World Psychiatric association. Int Psychogeriatr 1997;9(Suppl 1):11-38.

[15] ¹⁵
Fu C, Chutt DJ, et al. Comorbidity in dementia. Arch Pathol Lab Med 2004;128:32-38.

[16] ¹⁶
Brauner DJ, Muir JC, Sachs GA. Treating non-dementia illness in patients with dementia. JAMA 2000;283:3230-3235.

[17] ¹⁷
Tariot P. Medical management of advanced dementia. J Am Geriatr Soc 2003;51(5 Suppl Dementia): S305-313.

[18] ¹⁸
Bertolucci PHF. Doença de Alzheimer: o que esperar do tratamento e como identificar a resposta terapêutica? Alzheimer 2005;1:1-8.

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